Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to ensure the right of each resident to be free from abuse, as evidenced by a physical altercation between two residents in the hallway. Both residents involved had significant cognitive impairments and histories of behavioral issues, including aggression and resistance to care. On the day of the incident, one resident was wheeling himself towards the nurse's station when the other resident grabbed his shirt and struck him multiple times on the left shoulder. The altercation escalated, with both residents striking each other before being separated by staff. Video surveillance confirmed that one resident was the initial aggressor, and both residents were assessed by nursing staff immediately after the incident, with no visible injuries or complaints of pain noted at that time. Record reviews revealed that both residents had documented behavioral problems and required varying levels of assistance with activities of daily living due to cognitive and physical limitations. One resident had a history of aggression with staff and was noted to be resistant to care, while the other had a diagnosis of dementia, psychosis, and delusional disorder, with a care plan indicating a risk for aggressive behavior and a need for close monitoring. Despite these known risks, the facility did not prevent the altercation from occurring as the residents encountered each other unsupervised in the hallway. Interviews with staff indicated that they were aware of the residents' behavioral histories and the potential for aggression. Staff described previous incidents of aggression and confusion, as well as the need for interventions to prevent abuse. However, the incident in question demonstrated a failure to implement effective supervision and preventive measures, resulting in a physical altercation between the two residents. The facility's policies and procedures required protections against abuse, but these were not adequately followed to prevent the event.